About The Primary Care Coalition of Montgomery County, Maryland

The Primary Care Coalition of Montgomery County, Maryland was founded in 1993 when a group of physicians and health care officials imagined a Montgomery County where every resident had access to high-quality health services. They envisioned a dependable source of primary care for low-income, uninsured individuals in our community and created a framework that shared the responsibility for providing that care across the public and private sectors. The Primary Care Coalition (PCC) was formed to help make their vision a reality.

The PCC, a mid-sized regional non-profit, is deeply connected to the continuum of care for low-income uninsured, ethnically diverse residents of Montgomery County who frequently lead medically and socially complex lives. The PCC strives to provide a coordinated network of high-quality care for vulnerable residents of Montgomery County. The PCC works with the Montgomery County Department of Health and Human Services (DHHS), 12 independent safety-net clinics, six hospitals, and a number of other community partners to help patients’ access the full range of care they need. 

The mission of PCC is to be the catalyst for developing and coordinating a community-based healthcare system that strives for universal access and health equity for underserved community members. The vision of PCC is that all community members have the opportunity to live healthy lives, and that Montgomery County will be the healthiest community in the nation and a model for providing access to high quality and efficient care for all. To learn more please visit www.primarycarecoalition.org. 
 
Position Summary

The Behavioral Health Manager is the key regional facilitator for inter-organizational initiatives to reduce acute care hospital utilization and cost of care among those with behavioral health diagnoses.  The BHM reports to PCC’s Vice President Population Health who also serves as the Partnership Director (PD/VP) of the Nexus Montgomery Regional Partnership (NMRP), a collaborative effort among the six (acute care) Member Hospitals operating in Montgomery County and a network of community-based organizations.  The NMRP supports the Maryland All-Payer Model/Waiver, with the goal of reducing unnecessary hospital use by connecting people to community services that can help keep them healthy.  NMRP has three populations of focus: Medicare/dually eligible age 65+, hospital discharges at risk of readmission (all-payer and uninsured), and individuals with Severe Mental Illness (SMI; primarily Medicaid).  SMI is the initial population of focus for the BHM, with expansion into the other two populations as time allows.  This position requires strong strategic, analytic, relationship-building and facilitation skills.
 
The BHM is a member of the NMRP management team at PCC, develops collaborative relationships with local hospitals and BH community providers, and works together with the Montgomery County Core Service Agency (CSA) to access data and develop strategies for improving the long-term stability, function and health of those with SMI.  CSA is responsible for planning, development, monitoring and evaluation of publicly funded behavioral health care services.
 
Responsibilities
 

·         Develop relationships of trust and respect with community behavioral health leaders from hospital, county government, community-based organization and community providers. Serve on the Behavioral Health Workgroup of Healthy Montgomery, the cross-sector local health improvement coalition.  Work groups are tasked with identifying cross-organizational needs for improvement (e.g. gaps in services, care transition or communication procedures, technology or data sharing constraints), reviewing and recommending evidence based practices or other results-oriented solutions, developing work plans and metrics for pilot tests, and empowering organizations to do such tests. 

·         Facilitate change at a systems level - among Member Hospitals, community based behavioral health providers, Core Services Agencies, and policy and payer stakeholders – that results in reduction of acute care hospital utilization and cost of care for those with severe mental health diagnoses.  

o    With CSA support, obtain and analyze data on high cost and frequent acute care hospital users with behavioral health conditions, focusing at first on those with severe mental illness.  Identify trends and challenges at the local level.

o    Facilitate identification of policy, legal, procedural, and other barriers to diversion or expedient transfer of patients to more therapeutically appropriate and/or lower cost settings than an acute care hospital. 

o    Conduct literature reviews to find promising models that fit for the local environment and support outcomes of the NMRP.  This includes models that have a rapid and clear return on investment (e.g. crisis beds), those with more nuanced costs structures and returns (e.g. jail diversion programs) and longer term returns (e.g. supportive housing). 

o    Support the resolution of barriers through facilitating process, policy and work plan development among stakeholders, identifying needed subject matter experts (e.g. legal, data privacy, reimbursement policy).  Contract with and oversee subject matter expert subcontractors.

o    Interface with CRISP, the State Health Information Exchange, to advocate for sharing of Behavioral Health data as appropriate and as supported by the community providers and patients.

o    As needed, provide project management for cross-organizational initiatives.  Develop charters, champions, work plans to ensure progress and completion.

·         For models or projects requiring financial support to implement, create business case and budget models with evidence, through literature review or local pilot tests, for reducing Member Hospital cost of care for the severely mentally ill (SMI). With NMRP Director, present to NMRP Board of Managers and its committees for decisions on directing NMRP funds to initiatives. 

·         For two SMI interventions funded by NMRP (an 8-bed crisis house and an Assertive Community Treatment team focused on accepting referrals from the Member Hospitals, under implementation by Cornerstone Montgomery):

o    Work with Cornerstone Montgomery to ensure appropriate data is collected and timely reported for the success metrics being monitored by the NMRP Board and its Partnership Programs Intervention Committee (P-PIC).  Assist the NMRP Director/VP Population Health in determining return on investment for the crisis beds and ACT investments by NMRP.

o    Plan, coordinate and facilitate regular meetings with appropriate management at each of the hospital partners (e.g. legal, risk management, ED or Psychiatric Admission/Discharge), and crisis bed and ACT community providers to identify and address policy and protocol issues that may be barriers for ACT and Crisis Beds to successfully divert ED patients or reduce Length of Stay for inpatients.  With hospital and community providers, develop work plans to address identified issues.  Facilitate information, convening of work groups, or subcontracting consultants with specific subject matter expertise to ensure ACT and crisis beds are serving the needs of the Member Hospitals for diversion and reduced LOS.

·         Working with CSA, establish a process to identify ‘Super User’ cases, for whom existing resources are insufficient or have failed, resulting in continued high hospital utilization, high costs and/or poor outcomes.  Facilitate meetings with appropriate providers (hospitals, CSA, other relevant community organizations) to review cases, eliciting innovative solutions, collaborations, or means of coordinating services.  The service providers are responsible for implementing the proposed actions for their clients. BH SIM does not provide care coordination or service to any individual client.  Across case meetings, BH SIM collects information on barriers identified, actions taken and outcomes of those actions as input to discussions on systems change. 

·         As time allows, assist the two NMRP care coordination programs (Wellness and Independence for Seniors at Home, and Hospital Care Transitions) in program design regarding behavioral health.  Address program gaps in addressing co-morbid behavioral health conditions of the programs’ populations to the extent these conditions impact hospital utilization and cost of care. 

·         Support NMRP PD/VP in communications to the NMRP Board, HSCRC and other external stakeholders on programs performance, outcomes and recommendations; address impact on short-term and longer term population health goals and opportunities. As delegated by PD/VP, represent NMRP to external agencies and organizations. 

·         Identify and build opportunities for collaboration with local, State and Federal organizations, academic centers involved in behavioral health management and quality improvement efforts, and others to further regional reductions in hospital and total cost of care, ensure positive patient experience, and improve population health.

·         Engage with the PCC Montgomery Cares Behavioral Health Program Director to share learnings and ensure the NMRP and Montgomery Cares behavioral health programs are complementary, use similar metrics where appropriate and to further develop PCC’s culture of quality and improvement in behavioral health programs. 

Qualifications

·         Master’s Degree required:  MPA, MHA, Nursing, Social Work, Public Health or other related field.
·         Minimum five years’ relevant experience in a management role demonstrating coalition building, project management, quality or process improvement or program design expertise.  Must have experience effecting change across organizations.
·         Established professional with experience in behavioral health field.
·         Ability to establish oneself as a leader and advocate and to establish working relationships with health care professionals, behavioral health professionals, community resources, consumers.
·         Knowledge of the public health and mental health system in MD and in Montgomery County desirable.
·         Knowledge of Maryland All Payer Model goals desirable.
·         Knowledge of the broader issues such as housing, transportation, coordination of services which impact and affect individuals with SMI is desirable.
·         Knowledge of hospital policies and protocols related to risk management is desirable.
·         Demonstrated ability to work as a facilitator and colleague with multidisciplinary healthcare professionals. Excellent meeting planning, meeting facilitation and meeting follow-up skills required. Experienced in creating engaging, non-judgmental meeting environments that encourage sharing of challenges and failures and supportive peer-to-peer learning.
·         Computer literacy with proficiency and expertise in Microsoft Office, including WORD, EXCEL, and PowerPoint required.
·         Demonstrated advanced communication skills.  Ability to communicate effectively and persuasively, both orally and in writing to a broad range of stakeholders. Prepare and deliver effective presentations. Listen actively, build rapport easily, identify conflict and tension and facilitate constructive resolution, inspire and build trust.
·         Demonstrated ability to develop and monitor work plans across multiple organizations.
·         Must have good practices for staying organized.  Travel throughout Montgomery County to develop relationships and facilitate meetings is expected.  To facilitate integration with CSA, office space at PCC and CSA is anticipated; must be able to work from a variety of settings. Some meetings may be early morning or in the evening, must have flexibility for meeting times.  
·         Demonstrated analytical skills with sufficient statistical skills to define reports and analyses needed for data analyst staff.  Experienced reviewing and synthesizing subject matter literature. 
·         Self-motivated individual with the ability to work independently and with minimal supervision.
 
ADA Requirements

This job operates in a professional office environment. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

· This role routinely uses standard office equipment such as computers, telephones, photocopiers, filing cabinets and fax machines.
· This is largely a sedentary role; however, some filing may be required.
· This would require the ability to lift files, open filing cabinets and bend or stand as necessary.
· Advanced math skills needed to calculate compensation, bonuses, benefits analysis, percentages, etc.
· Requires ability to learn new software applications as necessary.
· Must be able to lift up to 20 pounds.
· May require occasional travel.

Disclaimer

This job description indicates in general the nature and levels of work, knowledge, skills, abilities and other essential functions (as covered under the Americans with Disabilities Act) expected of an incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of an incumbent. An incumbent may be asked to perform other duties as required.